DISTRICT CONSUMER DISPUTE REDRESSAL FORUM EAST Govt of NCT Delhi
CONVENIENT SHOPPING CENTRE, 1st FLOOR, SAINI ENCLAVE, DELHI 110092
Consumer complaint no. - 299/2015
Date of Institution - 05/05/2015
Date of Order - 22/07/2016
In matter of
Mr Rajveer Singh, adult
s/o Sh Bhagwan Singh
R/o- G-10, Akash Bharti Apprt,
Plot no.- 24,IP Extn.,
Patpargunj, Delhi- 110092. ……………………………………..…………….Complainant
Vs
The Manager
United India Insurance Co.,
10, Raj Block, Nr. Balraj Mandir
G T Road, Shahdara, Delhi-110032 ……..……….…………………….Respondent
Complainant’s Advocate - Sh Rajesh Kumar Sharma
Opponent’s Advocate - Ex Parte
Quorum Shri Sukhdev Singh President
Dr P N Tiwari Member
Mrs Harpreet Kaur Member
Order by Dr P N Tiwari, Member
Brief Facts of the case
Complainant is having mediclaim policy from OP since 2007 onward. He has submitted that he has never claimed for any ailment since policy was taken for himself and for his wife.
Complaint having Individual Mediclaim Policy from 10/03/2007 to 09/03/2008 vide policy no. 221503/48/06/20/00001169 for himself and for his wife for a sum of Rs 1Lakh each. Thereafter, complainant enhanced his sum assured from one lakh to 1.5Lakh vide policy no 221503/48/07/97/001143 from 11/03/2008 to 09/03/2009. He further renewed his policy from 2009 to 2010 and enhanced sum assured to 1.75 lakh. The next Insurance Policy was renewed from 2010 to 2011 with enhanced amount to 2.25 Lakh.
Further policy was renewed and a sum assured was enhanced to 2.50 Lakh in 2011 to 2012. Complainant renewed further and enhanced to a sum of Rs 2.75 lakh for 2012 to 2013. Complainant renewed for 2013 to 2014 and enhanced to a sum of Rs 2.75 lakh. The policy was renewed policy vide no 2215032814P111689540 from 18/03/2014 to 17/03/2015.
As per complaint, complainant had some chest infection and got admitted in Mangalam Hospital from 06/02/2015 to 07/02/2015, for one day. As cashless claim was rejected, so he paid his hospital bill Rs 16805/- and submitted his claim to OP which later was rejected u/clause 4.9 of policy terms and condition.
Aggrieved by rejection of his claim, filed this complaint and claimed hospital bill with 24% interest with Rs 50,000/- as mental agony and harassment. He also claimed Rs 15,000/- as litigation charges.
After scrutinizing complaint and evidence, notice was served. OP did not put his appearance nor submitted written statement or evidences. Despite of giving ample opportunity to OP, when none put up their appearance, case was preceded Ex-Parte. Complainant filed his evidence on affidavit. Case was perused with evidences.
It was seen that the said claim was rejected on the basis of discharge summary from treating hospital which state that “Patient was admitted with case of Acute Bronchitis and conservative treatment was given”. He was a smoker earlier but had left smoking. The treating doctor’s certificate showed that he was diagnosed as a case of Pneumonitis with Hemoptesis. Hence, claim was rejected under Misrepresentation of Facts under clause 4.9 which reads as taking Alcohol besides other heads.
It is clear from the duration of policies from 2007 to the claim period, complainant had not claimed. More so, mere mentioning of “Occasional taking Alcohol” had no findings in treatment papers nor was any side effect detected. Though, Acute Bronchitis was current diagnosis but hymoptesis is not seen in Acute Bronchitis. It mainly present in Active stage of Pulmonary Tuberculosis and superadded infection in TB is Bronchiectasis.
OP has not correctly and appropriately processed the claim. Alcohol has no relation with current diagnosis. As the policies were of more than four years old and were continue without claim, the pre existing ailments get covered thereafter.
Here, OP was Ex-parte, hence, taking the merit of evidence, filed by the complainant on affidavit, which are on record, the present complaint deserve to be allowed.
We pass the following order-
OP is directed to pay the hospital bill a sum of Rs 16,805/- with 9% interest from the date of filing this complaint, till realization. We further award compensation a sum of Rs 5000/- for harassment, mental agony and pain. In addition to this a sum of Rs 1000/- is awarded as litigation charges.
The order copy be sent to the parties as per act and file be consigned to the record room.
Mrs Harpreet Kaur- Member (Dr) P N Tiwari - Member
Shri Sukhdev Singh - President
